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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
"0..
' t' 6tate Form 43709 Department-09) A aL
Prescnbed by Department of Local Government Finance 1 '�x�`�,'Y�
INSTRUCTIONS:
Form filed wide
To be filed in person or by mad with the County Auditor or County Recorder of the county where the properly is local
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. JUN • 1 3County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ❑ County Recorder
See reverse side for additional instructions and qualifications. l. . • �� ••/
Applicant( rorcontract buyer-see_ -.. :.. %reveerseside) GIBSO COUNTY AUDITOR
Tan Di Key number/legal description Record number Page number
a✓ orb - //-/( - yoo -000 ..33 / - O rz ? 20 /3 ',533
Assessed vale of real property of Mortgage/Connors indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
en March 1,current year March 1.anent year date of application�/ f legal or equitable owner?
/5'QQQ ❑ Yes 0 No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with wham
If name on record is different than that of applicant indicate below
. a0 13
Name of mortgagee or contras seller 573 Draly r NO
Address of mortgagee or contract seder(number and street,city,stare.and ZIP code) a 5 3 3
Card NO.
Name of assignee or other owner or holder of mortgage 2 )oo. -
Address of /�• _ee(number and street city,/state,and ZIP code) �J U
„ea... ss-f,-e /°f'�� 3/ v r� . oS -4 C
Does applicant own property in any other If yes,what county? - What Taxing District? Has this deduction been requested on property .
county in Indiana? ❑ Yes ❑ No for wren(year?
❑ Yes ❑ No
COUNTY AUDITOR .
Deduction approved in the amount of
20 20 20_ 20_ 20 20 20
Signs trt of County Auditor. ,r • County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Xmare(owner's full name) Date(month,day,year)
u0 resident address apprcant(number a city,state,and ZIP code)
\ cb S . .-.00�.e.„ Q'`\,*- S.".%)e___
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 1 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) .